Welcome Aboard

What to Expect Now that You’re Accepted

One of the greatest days of my life was when I was accepted to medical school. It ranks up there with my marriage to my lovely wife, the birth of our children, the day I graduated Marine Corps boot camp and the day I was honorably discharged.

I’m not ashamed to say it. It was one of those days where the future opens up. When I was discharged from the Marines, for example, it was a beautiful April day in North Carolina. I had money in my pocket, an absolutely beautiful girlfriend who I would marry a year later, and nothing much to do until classes started in June. You feel like you can do anything at a moment like that.

Same with getting into medical school. So it is my fondest hope that those of you who have gained acceptance relish this time because the road ahead is long and you will probably have some dark moments. I also hope that those of you who will not get in this year continue to persevere, especially if you are young. Maybe I wouldn’t advise an older applicant to keep beating his head against the admission process but if you are in your mid-twenties, why on earth would you even contemplate giving up so easily after only one or two tries?

So good luck. Stand by. And here is some more unsolicited advice from your Uncle Panda.

First of all, you really don’t need to do anything to prepare. As I have said earlier, there are really no pre-requisites for medical school. I suppose it’s good that we take all of that organic chemistry and biology but I can’t really identify any area in my undergraduate education that was of any use. If you’re the kind of person that remembers everything from your sophmore biochemistry course then you probably will remember everything from your medical school biochemistry course. If you don’t even remember taking biochemistry as an undergrad then why worry about it? You will be exposed to it soon enough, you will remember it long enough, and by the end of fourth year you won’t remember enough of it to matter.

The point is you need to relax and take it easy between now and the middle of August when most of you will start. You cannot possibly cram everything you need to know between now and then. You can try, of course, but it is equally likely that absent any structured guidance you are going beat your head against subjects which will be breezed over in one lecture and never seen again. There’s just no point to cramming. Better to finish your coursework without totally dropping the ball and then take a well-deserved vacation, maybe the last time in your life that you are completely free of responsibility.

Those of you who are non-traditional or have families, would it kill you to quit your job a little early to take it easy for a while? Four years from now when you are a quarter million dollars in debt the couple of thousand bucks you wrested from your crappy job by sticking with it to the bitter end will not seem like that much money.

I was fortunate that I worked for myself and could wrap up my affairs well before my start date.

Second, and I know I am repeating myself here, do not buy anything on your school’s list of required books and equipment unless you don’t care about money. If you show up on the first day of orientation with a pen and a little piece of scrap paper to take notes you will be all right. Heck, eschew the scrap paper as you wil get reams of handouts. Besides most of what you will learn at orientation is pleasant to listen to but of no value at all once the proverbial excrement hits the fan. No need to take notes.

You see, at orientation they will fill your heads with visions of sugerplums which will dance in your head until the first day of actual class when you find that all of the happy talk and kumbayah won’t help you one bit as first year is just a grind, a pathetic slog through trivia.

Ah, orientation. It was a week of emotional masturbation during which we were told six hundred times that we were special, we were going to be empathetic, and gosh darn it, people liked us! Then classes started and people went from feeling warm and fuzzy to stressed, tired, and wound to the breaking point. Oh the bullshit they fed us, everything from “if you don’t study in a group you’re going to fail” to “get the textbooks because there will be required reading.” Har har.

So don’t believe the hype. Smile, enjoy the week (or however long your school allots for orientation) but prepare to get on it once real classes start. If you study, you will pass. If you study all the time, you may get good grades but then again you may only do a few points better than your slacker friend who studies one fifth as much as you. (Sometimes there seems to be no correlations between the amount of time you put in studying and your grade.) Study hard, keep up with the material, listen to good advice from your upper-classmen and try not to get to caught up in the touchy-feely stuff. You’ve got a long road ahead. No sooner will you start feeling like you’re in command of medical school when you will start third year and feel like the biggest superfluous, ignorant, non-essential piece of baggage to ever break the plane of the pelvic outlet.

Let me repeat one piece of good advice that one of the fourth years gave us during orientation. Be macho. No matter what happens just shrug it off as just another day. Big test coming up? No big deal. First day of General Surgery? Just another day. Step 1? Nothing to it.

Good luck.

Welcome Aboard

How It’s Done: Part One

A Day in the Life of an Intern.

Medicine Rotation. Two weeks down, three to go. Saturday morning. Today is “long call,” meaning that we will be here overnight as opposed to “short call” where we are the admitting team until two PM.

0530: I have the alarm set for 0545 but why bother? My eyes are open and if I go back to sleep I might sleep through the alarm and I’m not even sure if I turned it on last night. Had a dream that this was a day off and I could sleep in a little. Maybe until eight which I haven’t actually done since we had our first child almost nine years ago. Very disappointed when I realized that not only was this not the case but that this going to be a long day. Shower, shave, brush teeth. My black lab Persephone stumbles off the bed and lays down on the bath mat outside the shower as she does every morning.

0600: Check my email. My program is always sending threatening emails. I need to submit my duty hours for the last two months but the online software for this is pretty crappy and to enter my hours will take an hour or two which is why I haven’t done it. To hell with it. I’m certainly not going to do it now. Why are they bugging me about all the bureaucratic stuff anyways? I’m starting my new program in three months. What does it matter? Persephone has followed me downstairs and lays at my feet. My wife walked them (I have five dogs) at around four so I don’t really need to let her outside this morning. It’s raining anyways.

0610: Grab my pager, PDA, keys, straighten my tie, grab a couple of bagels and Cherry Diet Coke and head to work.

0630: Time to run the list. Only seven patients on the census this morning. we cap at seven admits. ICU admits, handled by the third year resident, count as two. Theoretically the list could get as high as fourteen but we have a few we can discharge today and a few rocks who are stable but immobile (with no expectation of discharge) and whose notes and plan should be easy to manage as it is essentially the same from day to day.

Mr. Smith, an incredibly emaciated man suffering from cancer who was admitted for pneumonia fell out of his bed ten minutes before I arrived I am informed by the on-call intern during a brief sign out for my team. Neurologically intact. Nasty knot on his forehead. He just bought himself a head CT. Do I need contrast? How is his renal function? Doesn’t matter. Non-contrast is indicated here. Renal function excellent but we have to supplement his mag and phos probably due to refeeding syndrome.

Mr. Jones liver function enzymes are normalizing. Liver biopsy tomorrow. Many nodules on his MRI suspicious for malignancy. Mental status at baseline which is not good. Still in restraints. Electrolytes OK. Renal function improving. Pneumonia, his presenting complaint buried among his competing co-morbidities is resolving. Still in respiratory isolation because once you start working somebody up for TB you have to carry on to the bitter end.

Ms. Green can go home. She has ruled out for an MI.

Ms. Black, still NPO. Fluids still running. Pain control. Treatment of choice for acute pancreatitis. Where does she get the money for her booze and heroin? We’ll start her on a clear diet today and advance to a regular, optimistically low fat, low salt diet if she tolerates it.

Mr. Good, you had us worried for PCP what with your HIV and an unknown CD4 count. It was nothing. Just Community Acquired Pneumonia. I’m not surprised you can’t afford your prescription for moxifloxacin. The remaining ten tablets will cost you close to thirty bucks which will seriously eat into your cocaine money. Don’t worry. We’ll hook you up. We always do. You have never, apparently, accepted responsibility for anything in life and it would be negligence on our part to expect this of you now.

0700: Meet with third year resident in charge of my team. The team consists of me, a medical student, a PA student, and the resident. Four teams, of course, as we are Q4 call. We run the list looking at everyone’s labs, vitals, and meds. On the computer, believe it or not, so I don’t have to run around collecting data. My resident is very thorough, very knowledgeable, and a pleasure to work for. Very efficient, too.

0720: Time to start seeing patients. There are two admits in the Emergency department already. This is goods news. Maybe we’ll cap early, like in the afternoon. This means that we might get some sleep. My resident goes to admit them, I start pre-rounding. The medical student and the PA student are each going to pick up one of the admits. I have five notes to write and one to co-sign. Not to mention new orders, as appropriate.

0740: Mr. Smith’s G-tube was pulled out as he fell. Did they save it? No. It’s in the trash. Rats. They should have tried to reinsert it immediately. Now the fistula has closed and the not even a narrow feeding tube can be inserted. Oh well. He will have to wait until Monday to eat because today is Saturday and interventional radiology will not come in today to replace the tube. Now I have to switch all of his “VT” (via tube) medications to IV. And there are quite a few. It’s things like this that eat up time. Fifteen minutes here, fifteen minutes there. Pretty soon it’s time to round. Surprise. Interventional is in house for an emergency and they will take Mr. Smith after they are done.

0900: Rounds. Sit down rounds in the resident’s work room. The best kind. We quickly review the old patients updating the attending on changes n condition or plan. The team going off call presents their new admits.

1000: Rounds. Only the interesting patients. Nine of us in the patient’s room while the medical students present. Mr. Clark with alcoholic pancreatitis which is being conservatively managed. NPO (no food, no water), IV hydration, and pain control. Mr. Marks with altered mental status, two year history of dementia who was finally LP’d (lumbar puncture, that is, a spinal tap) on this visit to the ED and who’s spinal fluid was VDRL positive leading to the diagnosis of neurosyphilis. How often do you see that? Penicillin in huge quantities has almost cured him. It’s miraculous, really.

1200: Work Rounds: Time to make sure all of the new plans for all the patients are implemented as orders to the nurses. New lab values and imagining needs to be followed up. Some patients can be discharged. The case managers are worth their weight in gold and you find yourself shamelessly kissing their asses as they alone can arrange skilled nursing care without which a patient like Mrs. Doe who has been on the floor for 170 days will never leave. You try to be compassionate but some patients overstay their welcome. You get tired of writing the same note every day and doing the same physical exam with the same findings. Can we make a big rubber stamp with the entire daily note and I can just pencil in the date. “Plan: discharge pending placement in skilled nursing facility.”

1400: Does every patient have a note? All are the labs ordered for tomorrow. Have all the labs been checked from yesterday? Anybody’s ions low? High? If so, why? Supplement the usual electrolytes for the gentleman detoxing up on the seventh floor. Slightly shaky but no real tremors. We had him on the alcohol withdrawal protocol and I guess he doesn’t really need the ativan but he is kind of squirrelly so we put him on standing ativan orders anyways. We will wean him tomorrow, or rather he will wean himself after discharge if he follows the instructions on the prescription. Either that or he will sell the ativan to buy booze. He complains about the ten bucks per month his blood pressure medicine will cost him. Ten bucks? Come on. That’s two bottles of Mad Dog.

Miss Purple, I know you don’t feel like going home but this is not a hotel. Of course we won’t just throw you out. The social worker has a taxi voucher for you. I’m sorry your life is a mess but nobody holds a gun to your head and makes you smoke crack. You’ve been off it for a week here recovering from your mysterious CVA-like episode so you obviously can do without it.

1500: Two new admits in the emergency department. The first has an impressive GI bleed. Shall I check his stool for occult blood? Couldn’t hurt…but he has passed about a 400 ml of blood in the thirty minutes he’s been down in the ED. A hematocrit (percentage of red cells in the blood) is 12. 40 is normal. The technetium scan showed an upper-GI source. But this is wrong because a later arteriogram showed a diverticular bleed which will be embolized by interventional radiology shortly. Young guy, too, so while diverticular disease is a possibility he may also have AVMs and we will work him up for this as soon as he is stable.

The second patient is 95 years old. In surprisingly good health until recently. No real medical history except an appendectomy back in the Truman administration. Had a fall. The EMTs reported slurred speech but once he gets his dentures in he’s perfectly coherent. Swears he tripped over his bedside commode. The usual syncope work-up, of course, including a head CT but the real concern is that he lay on the floor for twelve hours before he was found by his daughter. His serum myoglobin and CK are sky-high from rhabdomyolysis. A big risk to his kidneys so we will gently hydrate him with IV fluid. Gently because he has some congestive heart failure, undiagnosed until now, but revealed by his distended jugular vein and “pitting” edema in his legs. His lungs are clear so we’re not that worried about giving him too much fluid. Dialysis will kill him even if he is a candidate so we elect to “risk” the fluids to preserve his renal function. His seventy-five-year-old-daughter can’t care for him any more and he knows he is getting weaker so we will place him in a nursing home on Monday.

A lot of paper work. History and physical. Orders. Eats up the time.

1600: The other three teams have given up their pagers so now I am cross-covering for everybody. They have signed out a few key things to watch for in their more unstable patients but nothing really serious anticipated. Still, for the next 16 hours one pager or another will go off every ten or fifteen minutes with some routine (hopefully) question about a patient who I have never seen. “Sleeping pill? Sure!” “Restraint order? Why not.” The patient in 7117 just spiked a fever. 38.3. Is that high? I have to convert to Fahrenheit. Yes. Okay. Blood cultures, urine culture, chest x-ray. Otherwise patient doing fine.

1900: Grab something to eat from the cafeteria just as it closes. Not much of a selection but the server gives me a couple of extra pork-chops for free because they are closing.

2000 to 0500: A couple more admits. Small bowel obstruction. Obvious on the KUB (Abdominal film) as large, dilated loops of bowel. This is really a surgical patient but we will admit and they will follow. A naso-gastric tube to wall suction brings almost instant relief. Her vitals and appearance improve drastically. But still dangerous.

Many, many more pages during the night. Just enough to preclude the possibility of any real sleep. Still, it’s a slow night and with the exception of some chest pain nothing really serious. Just annoying. Can so-and-so have a laxative? Can you come talk to the family of a patient you know nothing about. Nurse annoyed that I know nothing about the patient. I explain cross-cover to her. “Is that safe?” she asks.

“No.”

Speed read the chart so I can sound authoritative. “Doctor, we’re not happy with the care our 76-year-old (demented, quadriplegic who should have been allowed to die peacefully after his third stroke) father is getting and we’re thinking of taking him to UNC in the morning.” You’ll make somebody on team 3 very happy if you do. Of course I don’t say that.

Respiratory therapy does not provide routine trach care. Can you please put in an order for the nurses to clear the patient in 4113’s airway every four hours?

0600: Start pre-rounding on my patients. Everybody’s vitals stable. Nobody’s labs too far out of whack. Write a few notes before rounding with my upper level at seven.

0700: Round with the upper-level who has had to mange our MICU patients most of the night as well as supervise the admissions. I always seem to miss something. I’m family medicine so we don’t spend as much time on the wards as the internal medicine interns.

0900: Attending rounds. Rounding on the new admits. Present the interesting ones at bedside. Time drags on. Enthusiasm for the minutia at it’s lowest ebb. Important to stay focused and answer the attending’s questions intelligently. The student’s presentations are maddening in their thoroughness. Look, it was just exertional chest pain of sudden onset relieved by rest and nitro. Do we really need the detailed description of the patient’s home life? This is why I am going into Emergency Medicine. Thirty minutes is just too long to talk about one patient.

1100: Now the mad dash to finish up all the work and tweak the plans for the new patients before 1:00PM when we have to be out of the hospital. The day float helps. We have thirteen patients now and there is a surprising amount of work to do. The new admits need brief notes. All the labs have to be checked and the imaging reviewed to make sure that everyone is lined up for Monday. It is Sunday morning and nothing routine will get done. Just emergencies but don’t hold your breath. Don’t get sick on a Friday at a community hospital.

1315: Everything done. Signed out to the on call intern. Out the door into the blinding sunshine. Short drive home. Kids watching cartoons before church. Maybe I’ll skip today and take a nap. Persephone brings the Frisbee to me so I have to go throw it for her in the front yard. She’s a real Frisbee dog and can catch them in mid air. The kids think she is a wonder dog.

How It’s Done: Part One

Yes, the Hours Still Suck

There is No Prize for Sucking it Up

Residency entails long hours. You may as well accept this and prepare for it. Up until very recently however the hours were much, much worse and it was not uncommon for residents to all but live in the hospital except for the polite fiction of being allowed to go home infrequently for sleep. These were the bad old day, only a few years ago, when you worked at the whim of your program with no recourse other than to quit if you didn’t like it.

These kind of hours were insane. Nobody can function on three or four hours of sleep every other day, at least not in something as complicated and intellectually demanding as medicine. As a young Marine I regularly went several days without sleep but while being a Marine requires considerable skill and intelligence, it’s nowhere near as demanding intellectually as medicine. You really do stop caring about things as you become sleep deprived. Everything requires more effort. Concentrating on routine (but important tasks) becomes impossible and it is only the occasional burst of adrenaline that makes functioning as a sleep deprived Marine or a physician possible.

In the old days when most of your older attending were residents, things were considerably different. It’s true that they spent long hours at the hospital but the pace was a good deal slower on the wards as there were both fewer interventions and a much slower turnover of patients. These were the days when the hospital course for someone with a heart attack was three weeks. Today it is usually two days, sometimes even one if the heart cath was done early in the morning and the patient is in otherwise good health.

It is one thing to be on call on a service with a census of patients most of whom are long term and stable boarders, it is another thing to be on call on a service with rapid patient turnover and a completely new census every few days. There is simply more work to do, especially when it comes to admitting patients.

“Admitting” is the process of working up the patient when he presents to the hospital and involves the history, physical exam, assessment, and plan which we discussed in a previous post. It is also as you can imagine a tedious paper-work grind at almost every hospital as previous records are tracked down, numerous forms are filled out (many of them redundant and mainly serving the purpose of lawyer-appeasement) and extensive notes are either written or dictated. It is not as tedious in private practice as the economics of paying a physician to waste time come into play but no such restriction apply at a typical academic hospital. Not only will you shoulder the burden of this work but you will also have to clear every decision through either your upper level resident or your attending.

This is the way it needs to be, of course (I mean except for the lawyer protection paperwork) but as a typical admission on a medicine service can take hours in the case of complicated patient you can see that with the rapid turnover in today’s teaching hospitals a few admissions a night will prevent you from getting any sleep when on call. In fact, most teaching services are “capped” or limited on the number of admissions they can take in recognition that learning is impossible if you are treated as cheap labor.

So I don’t want to hear the sanctimony from the old-timers about how much harder they had it back in the day. Fewer admissions and more stable patients lead to a more stable census and more time for rest. Sorry. The trouble was that as medicine became more complex and demanding, the treatment of residents lagged far behind almost as if it were in a different century. Residents working in modern, high-turnover hospitals were treated no differently than their more relaxed collegues from the fifties and sixties.

After several important papers were published detailing the risks to the safety of both patients and residents from sleep deprivation, the Accreditation Council for Graduate Medical Education (AGCME) mandated that all residency program restrict the work hours of residents to eighty hours per week averaged over four weeks. This is a good start but it’s still only a start.

The fact that many in the medical community think it takes eighty hours per week to train you in a medical specialty reflects the general inefficiency and poor organization of medical training as well as a reluctance of some to let go of old, outmoded methods. Eighty hours is better than 120 of course, but it’s not a pleasant way to spend three to seven years of your life.

Let’s look at a typical Q4 call schedule. This means that every fourth night is overnight call. You will work three 12 hour days. On the fourth day you will work through the night until one in the afternoon (you must be released by this time according to the rules). Since you got no sleep on call your half-day is pretty much wasted as you sleep most of it. You must be allowed one 24-hour period per week free from all clinical duties but sometimes this entails being allowed to go home in the morning after call which means that your day off is abbreviated to 20 hours or so.

You will usually end up working 85 hours a week if not more because some people will not let go of the old ways and as they have no life outside the hospital have no incentive to be efficient or decisive. Your time is not valued in the slightest because anybody who cares is paying the same whether you work fifty hours or a hundred.

The worst thing is that most of your time will be spent wrestling the incredibly inefficient paperwork system which is endemic to every American hospital. You will spend most of your time as an intern filling out some sort of paperwork or another. That’s why they still call your intern year a “clerkship.” Trust me, you will spend the majority of your time wrestling with the paperwork. Important or not, there is a huge quantity of it.

So eighty hours does make for a long week and a long month. It is a violation of an unwritten rule of residency to complain, of course. The tradition is to suck it up and not look weak. Still, it is a lot easier to spend your life at the hospital if you have no life outside the hospital which is more the case than you imagine. I had a third year resident on a medicine rotation who regularly rounded in the evening on non-call nights after every other team had gone home sometimes until seven or eight with me and the medical students as her entourage. The on call team was also in the hospital handling all of the new admits so we weren’t really doing anything. She just was just very dedicated but more importantly had nothing better to do with her time.

Patient care is important. On the other hand if you can’t manage twelve patients on your service from six in the morning until six at night then you have a problem with efficiency. All your over-night orders should be written well before normal quitting time and the nurses are more than capable of following them. The labs will cook without you and all of the consultants have gone home and will only suffer to come for an Emergency, delegating their interns to cover things. The on call team, for its part, is there for Emergencies and to follow a few key items for you which you relate during sign-out.

You can go home already.

The best part was that at the start of the rotation the resident lectured me that medicine needed to be my first priority and family and personal life a distant second. This attitude is incredibly patronizing. It is just a job and like most men of my age and upbringing I take work very seriously. I’ll do what needs to be done but medicine is not the military and it should not be necessary to sacrifice one’s family life to its service. Spending time with the wife and children is not a privilege, a reward, or something for which we have to beg.

So you’re not supposed to complain but I think as more and more non-traditional students matriculate into medical school and then into residency training there will be more complaining as the older you are and the more experience you have outside of medicine the less tolerance you have for chicken shit…which is what a lot of the antiquated customs of residency are.

I think the first thing that needs to be done is to eliminate or greatly curtail call. Everybody deserves to get a good night’s (or day’s) sleep. It should also not be a privilege to get some rest. Some call is pretty benign of course. Urologists pull call but there are few real urological emergencies so they sleep pretty well. Specialties like medicine need to go to a shift system. Either that or have a night float system where one week out of the month you work at night and sleep during the day.

Another thing that can be done is to add to the length of residency training. Maybe sixty hours a week isn’t enough time to train a medicine resident. Medicine is inherently inefficient as it deals with inefficient human beings so a lot of the wasted time is hardwired into the system. Add a year. Increase the pay a little and pay overtime for anything over forty hours like anywhere else.

Research any residency program thoroughly. Talk to the residents when you interview. Get a good idea of the call schedule and the hours because some programs are more benign than others.

Yes, the Hours Still Suck